Healthcare reform is an international challenge. So much so that it is seen as a top priority at the World Economic Forum. Over the last three years, policymakers have come to realise that paying for activity is potentially the root cause. But why is this so? And how could the system be changed? This article addresses these questions and looks for some answers.

Decisions are often based on how we or our employer is paid. A sales person paid on commission is persistent and promptly pulls out the contract and a pen.

Historically, the NHS has paid for services in two ways: either by block contracts, which pay for a service for a certain population, or by activity, where the commissioner pays for whatever treatments get done. With both of these payment methods, the organisation grows as it identifies more demand. And while health trusts have not gone out to create demand, what has been clear from attempts at reform, is that when demand increases there is no real reason to reduce it or to invest in prevention. After all, if you preside over a larger, more prestigious organisation, you're likely to be paid more and have greater recognition, both of which are strong motivators.

So what's the alternative? Outcomes are the new mantra. The 2010 Department of Heath white paper: Equity and Excellence said "there will be a relentless focus on clinical outcomes", a statement supported by the prime minister, deputy prime minister and secretary of state for health. This has started a range of programmes and work to pay for outcomes. Some are led by localities, such as the Milton Keynes, single provider contracting and others by the centre, through "year-of-care" pilots. If you pay for an outcome then, theoretically, it is up to the provider to achieve the results, no matter how it is done.

Let's say if we pay £200 for "recovery within three months of having a fall", then at least we know that something real has been achieved for the patient. This is a step forward, but it still doesn't prompt prevention. To make prevention reality, we need to measure things differently.

In 1953 Virginia Apgar introduced a 10-point score to evaluate the condition of newborn babies. This simple score gave clinicians clear, graded feedback on the success of delivery and could predict whether babies would survive until 28 days. It encouraged development of practices to improve outcomes.

This inspired the American surgeon Atul Gawande, to create an equivalent for surgery. What is interesting about both of these scores is that they are holistic and motivate prevention. If a surgical team sees certain types of patients who have low scores then, to improve quality and outcomes, they know that they need to develop and implement practices which reduce the number of patients with low scores. They may initially try different packages of care, which don't have an impact and then find methods which seem to work. This is how the obstetrics score motivated change in maternal care.

So far, such scores have not become scales for payment, but even as quality measures, they have motivated innovative, preventive practices.

Perhaps Virginia Apgar's idea contains a seed to reforming healthcare incentives? Could we develop Apgars for health? Let's say, for respiratory health, neurological health or cardiovascular health? Beginning a change from measuring activity to measuring outcomes in a preventive way? Could we use such scores as contracting measures to trigger payments?

We are doing some work here to develop outcomes and measures to contract for health improvement rather than just dealing with illness. The language is slightly different, but the impact could be profound.